One of the saddest threads I have every read on Pprune and not just because of the unfortunate outcome but also, I’m afraid, because of the nature of some of the posts. I have been following this from the very start and I should congratulate some of the early posters for their insightful observations while the facts were still very thin on the ground.
We now have an NTSB report which gives us a much fuller picture of the tragic events that took place, but I am shocked by the callous and blinkered interuptation that some are putting on this report. It is clear to me that there are at least 4 significant contributers to this fatality but some are happy to pin the entire events on a reckless crew who were just having a bit of fun. Oh, how quick the authorities were to release that gem of a one liner. It was released in the hope that everyone would agree with their interuptation and go away quietly, and I am saddened at how quickly the aviation fraternity has obliged. We owe it to the unfortunate crew not to let this happen. I urge all to reread the report and re evaluate your opinions on the events that happened. Here is how I see it.
The Crew.
There can be no question that the crew took the a/c to it maximum certified limit of FL410 having been cleared to a much lower level, but as someone has already pointed out, it was the maximum certified limit and not beyond it. I am only too well aware of the “special” aerodynamic circumstances that exist at this altitude and that special training is required to both handle an a/c at that limit, and to recognise the onset of the various phenomena that occur there. This wasn’t provided nor was a lower limit imposed by the operator through a mandatory SOP or similar instrument at their disposal. I find it interesting that the report notes that the service agent who met the crew prior to them embarking, found them in very good mood and not at all tired looking. I suspect that the crew knew only too well that they were being handed the keys to the sweet shop and that the special circumstances surrounding the flight, a repositioning flight with no pax or cargo, would give them the opportunity to go for the magical 41. I would even speculate that they may have even discussed it before hand and would credit them with having probably evaluated the risks within the limits of their knowledge, however flawed this may have been. Unfortunately they were not prepared by the Operator for what was to come.
The Operator.
I hold this bunch in the highest contempt of all. Interviews with sim instructors and checkairmen revealed that high altitude climbs and recommended climb profiles were neither conducted, discussed or demonstrated during sim training sessions with crew on this type. They were simply discussed in the jet upset module of the ground studies. This to me is only acceptable if accompanied with an SOP or some other mandatory circular to all crew forbidding them from attempting to get to an altitude above say FL370. Further more, the report reveals that the only sim based upset training provided to new pilots consisted of 20 minutes where the operator didn’t even allow the pilots under instruction to climb to FL350 but positioned them there electronically to save money (or time as they quite disingenuously put it). This to me demonstrated this operator’s commitment to safety right there. Appalling. The report has a comment from a management pilot from another carrier who operate the same fleet, and he stated that his FDR data analysis from repositioning flights “seems to bring out the worst in his pilots” with unusual attitudes and other manoeuvres regularly being tried. I assume Pinnacle have similar data but didn’t use it to prevent this practice – it probably costs too much. Just look at the number of changes both Pinnacle and Bombardier have made to ops procedures since this incident – staggering in my opinion.
Bombardier
Why oh why would you apply for and get a certificate to operate an a/c at a flight level that required at the very least special training. Several pilots are on record that while they were able to climb to FL410 they were not able to maintain it due to deteriorating performance. If FL410 can’t be safely maintained, why is it certified??? One experienced instructor commented that FL410 required “extreme” attention while another stated that “FL410 is not a FL you want to be at very often” Because it was certified, the two crew in this accident probably felt that it could be safely achieved.
FAA
Why would they give a certificate to an a/c to operate at FL410 with these characteristics? Further more, they issued 59 violations against Pinnacle between ’98 and ’04, and some were not even remedied by them. However, the speed at which Pinnacle implemented every recommendation of this report suggests that something is very wrong.
Conclusion.
Come on folks; don’t let them take the easy way out.
.
May they rest in peace.